NCLEX-RN
NCLEX-RN Exam Questions
Extract:
Question 1 of 5
A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
Correct Answer: D
Rationale: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.
Question 2 of 5
A client who is gravida 1 para 1 vaginally delivered a 7-lb girl. She received a midline episiotomy at delivery. When assessing the level of her uterus immediately following delivery, the nurse would expect the fundus to be located:
Correct Answer: D
Rationale: Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. The uterus descends into the pelvic cavity at approximately 10-12 postpartal days and can no longer be palpated abdominally. Within 12 hours of delivery, the fundus of the uterus rises to, or slightly above or below, the umbilicus. Fundal height generally decreases 1 fingerbreadth, or 1 cm/day. An enlarged uterus may indicate subinvolution or postpartal hemorrhage. Immediately following delivery, the uterus lies midline, about midway between the umbilicus and the symphysis pubis.
Question 3 of 5
The nurse is caring for a client diagnosed with metastatic cancer of the bone. The client is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
Correct Answer: B
Rationale: Hypercalcemia (calcium 13 mg/dL) is a common complication of bone metastases, causing confusion and hypertension. Hyperkalemia (
A), low phosphorus (
C), and normal sodium (
D) are less likely causes.
Question 4 of 5
A client is started on prednisone 2.5 mg po bid. Which of the following instructions should be included in her discharge teaching specific to this medication?
Correct Answer: B
Rationale: Fluid retention is a side effect of prednisone. The nurse should teach clients to weigh themselves daily and to observe for signs of edema. If these signs of fluid retention occur, they should notify the physician. Prednisone, a glucocorticoid, suppresses the normal immune response making the client more susceptible to infections. An increase in bleeding tendencies is a side effect of prednisone therapy. The nurse should teach clients to use preventive measures (i.e., electric razors and soft toothbrushes). Depression and personality changes are side effects of prednisone therapy. Prednisone should never be discontinued abruptly.
Question 5 of 5
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
Correct Answer: C
Rationale: This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client. This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior. Redirection is appropriate for the client who is out of touch with reality. This answer is correct. Manipulative clients must abide by consistent rules. This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.